Nicotine Dependence Treatment

TREATMENT
Non-pharmacologic treatment
Studies have shown that simply advising your patients to quit along with
agreeing on a quit date can be helpful. Even more effective are behavioral
therapy and motivational interviewing—but that may not be available to
certain patients, depending on where they live and what kind of insurance
they have (see Chapter 4 for information on motivational interviewing).
Fortunately, there are several free resources, some of which are paid for
by manufacturers of smoking cessation treatments. The best portal is the
phone number 1-800-QUIT-NOW, and there are various affiliated websites.
One is www.smokefree.gov, maintained by the U.S. Department of
Health and Human Services. Patients can get diaries and calendars to support
their efforts, and they can sign up for a phone call or text message on
their quit date, as well as follow-up calls or texts. The site also has information
on using diaries and calendars to support quitting efforts. While these
programs are designed to be used in conjunction with nicotine replacement
therapy or other pharmacologic treatment, they are helpful for anyone.
DOCTOR/PATIENT DIALOGUE: Motivational
Interviewing to Persuade a Patient to Quit
Doctor: Have you thought about quitting smoking?
Patient: Smoking relaxes me.
Doctor: Yes, it can help people relax. What else do you like about
smoking?
Patient: Like? No doc has asked me that before. Let’s see . . . I like
taking a break during the day. I like talking with people who are also
outside smoking. That first cigarette of the day is the best. I used to
look pretty cool lighting up and puffing away in front of my friends,
but that got kind of old after a while.
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Doctor: So the excuse to take a break during the workday is good,
and the first cigarette of the day is the best one, but lighting up isn’t as
cool now as it used to be. Is anything else not as much fun as it used
to be?
Patient: Well, it costs real money, that’s for sure. And going outside all
the time gets old, too. If I knock over an ashtray in the house, cleaning
it up is a pain. I also don’t like that I can’t give it up, even for a while.
But if I didn’t have my cigarettes, I couldn’t make it through my day.
Doctor: So it’s expensive, it takes some time in your day away from
other things, and cleaning up is a hassle. Anything else?
Patient: My mother quit when she was younger, so she’s on my case
about me smoking. I swear, she brings it up all the time. I’ve taken to
hiding the ashtrays when she comes to visit, and I sneak out of my
own house to take a drag, just to avoid the hassle.
Doctor: So your mother would support you if you would try to quit,
and she would be proud of you if you did?
Patient: I guess so.
Doctor: That sounds like something to think about.
Patient: Yeah, I’m sure I’ll try to quit again someday. I’m not ready
now.
Doctor: You’re right; it’s worth thinking about quitting again. You
might find you can relax without a cigarette. It might even help your
depression.
Patient: I suppose so. I’ll think about it—especially if it could help
my depression.
Doctor: Is it all right if I ask about that at our next visit?
Patient: Okay. I’ll let you know.
Pharmacologic treatment
Nicotine replacement therapy (NRT)
NRT supplies an alternative source of nicotine to help your patients
decrease and ultimately quit smoking. I recommend starting with NRT
before moving to bupropion or varenicline, because it’s widely available
and readily acceptable to most smokers.
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Which NRT to choose? There are lots of options, but generally you
should start with the patch, because it delivers a constant nicotine level
throughout the day, hopefully preventing episodes of craving. (For really
light smokers, you can start with nicotine gum—see below.) Patches used
to be expensive, but prices have come down as more chain pharmacies have
created their own products. At this point, a month’s supply will generally
cost about $1 per day.
Which dose of the patch should you prescribe? It depends on your
patient’s current nicotine consumption. A typical pack-per-day smoker is
consuming about 20 mg of nicotine per day, so in this case you would prescribe
the 21 mg patch. If the patient smokes 2 packs per day, 2 patches may
be needed, but this (and even lesser doses) may be too much, and some
patients will simply discontinue the patch if they have adverse effects. It’s
recommended to counsel patients that they can reduce the dose if needed.
I tell patients to apply the patch at the same time each day, usually in
the morning. One potential exception is the smoker who wakes up with
a strong craving to smoke. Such patients can try applying the patch close
to bedtime, following the theory that the residual morning nicotine will
prevent their initial craving. A common problem with nighttime administration
is vivid dreams or nightmares, so warn your patient: “You might
notice some funky dreams.”
In terms of where to place the patch, tell your patient to start by placing
it just above the heart (the upper anterior chest), then the next day move
it left to the upper arm, then the left upper back, right upper back, right
shoulder, right chest, and finally back above the heart. This rotation helps
prevent skin irritation due to the adhesive. If there is any irritation, 0.5%
cortisone cream helps. Usually no shaving is required. Swimming with the
patch is fine, and patients who think they’ll be embarrassed by wearing a
patch on the beach can be reassured that patches are clear now and pretty
hard to spot.
Have your patients stay on the initial dose for 4–6 weeks, then use the
next-lower strength for 4 weeks, and so on. Some patients need a longer
taper—for example, they may need 3 months on the initial dose, and then
a very slow taper thereafter. Advise patients not to smoke while taking the
patch, but let’s face it—some will. With this in mind, be realistic and tell
them that if they do smoke, they may develop nausea, which is the first
symptom of nicotine toxicity.
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NICOTINE PATCH—AT A GLANCE
Indication Tobacco cessation
Dosages available 7 mg, 14 mg, 21 mg
Target dose Start 14 mg–21 mg daily, then gradually taper over
several weeks
Comments Several other forms of NRT are available, including
gum, lozenge, and spray
Combination NRT
Some patients find that they have cravings throughout the day even while
using the patch—if so, recommend one of the short-acting NRT agents,
such as the gum, lozenge, or spray, in combination with the patch. In fact,
light smokers may do well starting with one of these agents and skipping
the patch entirely.
A word on nicotine gum: Its chewing technique is different from regular
gum. Patients should start by chewing a few times to activate the release of
the nicotine; they’ll know it’s releasing because the gum will start tasting
bad and peppery. At that point, they should park it between the cheek
and the gums, and switch sides every several minutes or so. One piece of
gum releases a total of either 2 mg or 4 mg of nicotine, and it lasts about
30 minutes.
While the gum is the most popular short-acting treatment, some patients
will prefer other options, such as the lozenge or the spray. The lozenge is
easy to use—patients just pop one in like a piece of hard candy when they
have the urge to smoke. Nicotine nasal spray is available by prescription and
involves frequent dosing of small amounts of nicotine. Its use is limited to
six months to prevent development of physical dependence on nicotine
(obviously counterproductive given the goal of tobacco cessation).
Varenicline (Chantix)
Chantix acts as a partial agonist at nicotinic receptors, so its mechanism is
physiologically closer to nicotine—which is our rationale for choosing it
over other medications, such as bupropion. Some patients will move on to
Chantix after an unsuccessful trial of NRT, but others want to start with the
pill right away, which is reasonable.
While Chantix’s manufacturer has a dosing recommendation, different
clinicians have their own preferences based on experience. I start patients
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with 0.5 mg per day for 7–10 days, at which point they should stop smoking
and increase to 1 mg BID, then continue at that dose for 3 months. However,
a recent study found that patients don’t have to quit that soon after
starting Chantix to respond to the drug. In the study, smokers were asked
to reduce their smoking gradually over 3 months while taking Chantix, and
their long-term abstinence rates were robust—27% at one year vs. 9.9%
on placebo (Ebbert et al, 2015). This is good news because some patients
panic when told they have to try quitting in a week.
Chantix’s potential psychiatric side effects have been widely covered, but
in my opinion, they’re overblown. A recent meta-analysis of 39 randomized
controlled trials covering 10,761 patients found that there was no difference
between Chantix and placebo in rates of depression, suicidal ideation, or
aggression (Thomas et al, 2015). However, Chantix did cause more insomnia
and abnormal dreams in these studies, which jibes with my experience.
Tell patients about the possibility of vivid dreams and nightmares (though
nightmares aren’t very common). If this is a problem, have them take the
pills in the morning.
VARENICLINE (CHANTIX)—AT A GLANCE
Indication Tobacco cessation
Dosages available 0.5 mg, 1 mg
Target dose 1 mg twice daily
Bupropion (Wellbutrin, Zyban)
One large study reported that bupropion SR led to a 23% one-year quit rate
vs. 12% for placebo (Hurt, 1997). While the manufacturer recommends
starting at 150 mg per day for 3 days then increasing to 150 mg BID, studies
have shown that continuing with 150 mg/day is just as effective as the
higher dose—and has fewer side effects.
Most psychiatric prescribers are quite familiar with bupropion’s common
side effects of insomnia and anxiety. A potentially good side effect is weight
BUPROPION (WELLBUTRIN, ZYBAN)—AT A GLANCE
Indications Major depression, SAD, tobacco cessation
Dosages available 75 mg, 100 mg, 150 mg, 200 mg
Target dose 300 mg for smoking cessation
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loss, since people trying to quit smoking often substitute food for cigarettes.
Note that bupropion is contraindicated in patients with a seizure disorder
or with a history of bulimia or anorexia nervosa.
Off-label meds
Two medications, nortriptyline and clonidine, are effective second-line
agents for smoking cessation, though this is an off-label use for both. Nortriptyline
is usually started at 25 mg daily 10–28 days before the quit date,
then gradually increased to 75 mg–100 mg daily. Treat for 3 months at this
dose; the treatment can be extended to a total of 6 months depending on
response. Nortriptyline should be tapered off instead of stopped abruptly
due to possibility of withdrawal effects. Clonidine is dosed starting with
0.1 mg daily, then increased gradually as tolerated by 0.1 mg/day to a 0.15
mg–0.75 mg total daily dose. Clonidine should also be tapered off to avoid
rebound effects.
CASE REVISITED: Since Y had tried nicotine replacement therapy without
much success, I recommended varenicline. I also recommended nicotine
lozenges to use if she had cravings that she could not overcome with
distraction techniques. I gave her information on 1-800-QUIT-NOW
and smokefree.gov, and I encouraged her to access the online behavioral
program that came with her varenicline prescription. Finally, I encouraged
TABLE 9-1. Tobacco Cessation Drugs
Product Dose Side Effects
Nicotine patch 7 mg, 14 mg, 21 mg/day,
depending on nicotine use
Application site reactions
Nicotine gum 2 mg–4 mg every 1–2 hours as
needed
Headache, indigestion,
nausea
Nicotine lozenge 2 mg–4 mg every 1–2 hours as
needed
Headache, indigestion,
nausea
Varenicline
(Chantix)
Start 0.5 mg/day, increase to 1
mg twice daily
Insomnia, vivid dreams
Bupropion
(Wellbutrin, Zyban)
150 mg, either once or twice
daily
Tremor, insomnia, weight
loss
Nortriptyline
(off-label)
Start 25 mg daily, increase to 75
mg–100 mg daily
Sedation, dry mouth,
constipation
Clonidine
(off-label)
Start 0.1 mg daily, increase to
maximum of 0.75 mg total daily
Hypotension, sedation, dry
mouth
140 THE CARLAT GUIDE SERIES | ADDICTION TREATMENT
Y to let her coworkers and friends know about her quit attempt, so that
nonsmokers could offer her support and her coworkers would not try to
tempt her back into smoking.
QUITTING AND PREVENTING RELAPSE
Unfortunately, most patients relapse, even with the fanciest of meds and
behavioral therapy; let them know that there’s no shame in failing to quit.
I say things like, “You may have to try this several times—and that’s okay.”
Often I’ll invoke the Mark Twain quote that leads off this chapter.
The first week after quitting is the hardest in terms of craving. A typical
smoker gets about 10 puffs out of a cigarette, meaning that a pack-per-day
smoker gets 200 doses of nicotine over the course of a day. That’s a lot
of habituation and reinforcement the patient must overcome. Triggers
for craving are everywhere—seeing the ashtray, having coffee, having a
drink, going to the corner store, etc. Distraction techniques can work well,
because nicotine cravings generally only last 10–20 minutes. Patients can
do things like drink a large glass of cold water or play a video game to get
their minds off the urge.
I recommend warning patients that they are likely to cough temporarily
after they quit—this is a normal response as the cilia of the lungs “wake
up” and get rid of mucus. If not alerted to this, some patients will worry
unnecessarily.
In my experience, even with the high rate of relapse, patients who are
willing to stick it out with you over time will have at least a 50% chance of
prolonged abstinence.
Here are some practical tips for successful quitting and relapse
prevention.
• Set a quit date. Have the patient set a significant quit date, such as a
birthday or anniversary, to enhance motivation. Conversely, a quit date
can be set during a time when the patient has less stress and can deal with
the difficulties of a quit attempt. Before setting a quit date, I recommend
patients immediately start gradually reducing their daily number of cigarettes.
This way, they will be smoking less before they stop completely,
which can help with the severity of early nicotine withdrawal symptoms.
They will also start to get used to those symptoms, at least to a degree.
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• Tell friends and family. If other people know the patient is quitting, they
can provide support. Family, friends, or coworkers can also help keep the
patient accountable—if the patient lights up a cigarette around them, they
can say, “I thought you were quitting!”
• Have everyone try to quit together. If the patient has a partner or
roommate who is a smoker, the patient is much more likely to relapse. If
both try to quit, they can support one another and are much more likely
to be successful.
• Reduce the prevalence of cigarettes. Here are a few ways:
– Limit smoking to outside the home. This helps the patient to think twice
about automatically lighting up. It makes smoking intentionally less
convenient. If smoking an individual cigarette becomes more of a
hassle, the patient is more likely to say, “Forget it; I’ll just smoke later.”
– Get rid of all but one ashtray in the home. Then get rid of the last ashtray
on the quit date.
– Switch to a different brand of cigarettes. The difference in taste from a
new brand can help reduce the number of cigarettes smoked per day
and remind patients that they are not supposed to be smoking as much.
However, switching to “light” (lower-nicotine) cigarettes doesn’t
work—patients just smoke more cigarettes to make up the difference.